Coming from a nursing background myself, I’m always fascinated by the work going on in virtual environments in regards to nurse education. To some extent it’s a natural fit in that clinical simulation is a pivotal part of the education process for nurses anyway – using virtual environments is simply an extension of recognised practice.

Evelyn McElhinney (SL: Kali Pizzaro) is a Nurse Lecturer in the post-registration department of Glasgow Caledonian’s School of Health. She teaches a number of advanced practice modules including modules within the Nurse Practitioner pathway. She joined the university full time 3 years ago, and was a lecturer/practitioner working in an advanced practice role within the National Health Service prior to that and has worked in a number of acute care areas including anaesthesia. Evelyn also happens to be active in the use of Second Life in Nurse Practitioner training, so I caught up with her to discuss her work to date and some broader issues around collaboration.

Lowell: From a nursing education viewpoint, what are your key areas of professional interest / research focus?

Lowell: When you say nurse practitioner, can you define that a little? I’m assuming you mean someone undergoing their undergraduate nursing education?

Kali: Ah no in the UK Nurse Practitioners are Registered Nurses who are advancing their practice. A nurse who takes a history, physical examination, diagnoses, prescribes and treats.

Lowell: Ok, that’s similar to Australia then. So are there particular advantages for using virtual worlds with more experienced nurses like practitioners rather than nursing students?

Kali: The advantages are that they need flexibility as they have competing demands on their time. So any medium that allows for extra practice in a time conducive to them is attractive. However, virtual worlds can do more than the usual virtual learning environment.

Lowell: When did Second Life become a consideration in your work?

Kali: I considered Second Life after seeing a project by one of my colleagues. I had know about it’s existence as the University had a project exploring it’s use for marketing. That was in March this year.

Lowell: Can you describe the work you’re doing in Second Life and how it links to the University’s CU There initiative?

Kali: I am trying to develop a virtual patient which will be used by Nurse Practitioner students to practice history taking. I have also embedded heart sounds into the avatar’s chest to enable the student to link the history to the heart sounds they hear. They must click on the correct anatomical position to hear the sounds. This work links to the CU There project as it fulfills the criteria for use of virtual worlds in education. By creating an AIML bot/bots the students have the flexibilty to practice at any time either as an individual or as a group. I plan to have a number of patients and to build on the sceanrios to create longer problem-based learning scenarios. The bot we use were developed by myself and the School technician Andy Whiteford aka AndyW Blackburn.

Lowell: So what level of work has been required to get the lab to this stage and how much more is involved to get it to where you’d like it to be?

Kali: The clinical skills lab was designed by the CU There team with guidance from the head academic in charge of the simulation lab . The build was done mainly by a computer student who is seconded to the team. There are plans to build an ITU for a scenario for 3rd year students. For my scenario it is mainly me thinking of ways to expand each scenario in alignment with the needs of my students.

Lowell: The most common feedback I’ve gotten from nursing academics is a skepticism on what virtual worlds offer that a well integrated curriculum with comprehensive leraning management tools can’t, that is, aside from the advantage of not needing to get students to a real-world simulation lab, are there other benefits of working in environments like this?

Kali: The immersive environment enables authentic scenarios to be developed. There is also the ability to offer syncrounous text and voice communication, as well as the ability to show the whole class videos etc. We can also simulate things that would be difficult in real life.

Lowell: Is there an example of that you currently use?

Kali: Not at the moment. However, for undegraduates it could be useful for them to be inside a heart or lung to understand the anatomy and physiology. It is also much more interactive than other VLE’s.

Lowell: I suppose that’s the crux of the challenge for nursing educators using virtual environments: convincing others that things have moved beyond the gimmicky, would you agree?

Kali: Yes, you need to show them something that is pedagologically sound, something they can see is useful.

Lowell: On pedagogy, what do you see as the key foundations in your work and in virtual environments more broadly?

Kali: Constructivism and social constructivism are the key learning theories in my work. By linking history and heart and lung sounds to other parts of a clinical scenario, I am building on the students previous knowledge to create new knowledge. People in simulations tend to act the same as they do in real life. The ability to capture the text allows for reflection on the decision-making of this particular group.

Lowell: What has the feedback been from students?

Kali: Positive- they can see they value. They feel they are in the sceanrio. However, it is early days. We have only had a few folk through as a pilot. We will be using it more in the next two semesters.

Lowell: Are there formalised evaluations planned on clinical skills training in Second Life ? Will there be comparative studies on those who used such tools versus those who didn’t and their subsequent outcomes?

Kali: Yes, a number of academics are evaluating their projects and one is plannning to compare in-world and out-of-world simulation. Some of these are through a University scheme, Caledonian Scholars.

Lowell: What’s your take on nursing research in virtual environments internationally? Is it fair to say it’s still very early days?

Kali: Yes, there are a number of good projects. However, it is still in it’s infancy. Simulation seems to be the most popular project.

Lowell: Is there any research completed or underway that has particularly interested you?

Kali: It’s still in publication, however a lot of what the students said was that they wanted to experience areas they had not been to, and that they also found the scenario exhausting. Interestingly, they did not do a single observation in an hours sceanrio in a busy surgical ward. They also did not know what to do with a patient who was demented and kept leaving the ward. I think they were too busy thinking what to do next, this was despite being prompted to do observations.

Lowell: You raise a very interesting point – perhaps virtual environments make a more natural stage for making errors as there isn’t the stress of the educator looking over their shoulder?

Kali: Maybe, although this sceanrio had educators involved. Although that is the beauty of simulation – make mistakes and no-one dies 😉

Lowell: For the nurse who has been working in either a hospital or community setting for five years or more, how do you make virtual environments like Second Life an appealing and logical extension of their professional development needs?

Kali: By making the scenarios authentic and as realistic as possible. Also they must be available at all times to ensure maximum flexibility. The student must see the value to be motivated to take part. If they are fun, then great.

Lowell: Do you think Second Life is at a stage of usability that it can achieve that now?

Kali: Not yet in the UK – it is still not widely know as a social tool. However, if it is introduced in education they may see more value, as it helps them to learn.

Lowell: On usability though – it’s still quite a learning curve to actually use, particularly for those not as net-savvy as others?

Kali: Well you could say that about any VLE, and it is really only arrows and clicking. Changing clothes is not mandatory for education. Well, not all education. I think most folks would get it in a short space of time with some guidance.

Lowell: Again specific to nursing, is there any great degree of collaboration going on internationally in regards to projects like these? How do you think nursing faculties could further improve collaboration?

Kali: We are exploring a couple of collaborations. I know Scott Deiner in New Zealand has collaborated with American colleges. However, there is the potential for major collaboration both nationally and internationally. Although you need to have a firm idea about what you want to collaborate on. Also there is still a little bit of folk finding their feet, so to share is still scary methinks.

Lowell: Do you think there’s the critical mass for organised collaborative structures such online journals or other formats for working together?

Kali: There could be, and the Virtual World Watch here has opened up avenues for collaboration by highlighting the people who are involved with virtual worlds, although there is a bit to go.

Lowell: So for a nursing academic looking to integrate virtual environments into their teaching or research, would you have any simple advice?

Kali: Make sure you think about what you want to use it for. Script the scenario and look around at other people’s work to find out what the virtual world is capable of. Also visit educational areas and talk to other academics or join a group. Make sure there is a strong pedagogical structure to your idea and show it to folks when you have something to show!! Seeing is believing.

——–

To view the publicly accessible clinical skills laboratory in Second Life, go here.

(This story originally appeared over at sister-site Metaverse Health earlier this week).

Over the past few weeks, there’s been a spike in mainstream media interest around virtual environments and health. I thought it’d be worth showcasing three notable stories / issues that you may not be aware of.

Amputee Support

A press release from ADL Company Inc. and Virtual Ability, Inc. touts the launch of a project to provide peer-support to those who have undergone amputation of a limb. The project’s impetus has come about due to some sobering US-based facts:

Recent US military casualty figures for Operation Iraqi Freedom and Operation Enduring Freedom indicate that between September 2001 and mid-January 2009 over a thousand amputation injuries occurred. Of the 935 amputations considered major, one in five wounded warriors lost more than one limb. While the rehabilitation goal is for the soldier to return to active duty, many reintegrate into their civilian communities. In either case, military amputations are often accompanied by additional wounds, depression, fear, phantom limb pain, and post traumatic stress disorder.

Spouses and family members often become the caregivers of military amputees after they are released from military hospitals and rehabilitation programs. Family support members have their own grieving process to go through related to the amputation and to the change to family life.

New Scientist has a good article on a study looking at brain activity (as measured by MRI) when discussing perceptions of real self versus a heavily played World of Warcraft character. The methodology:

To probe what brain activity might underlie people’s virtual behaviour, Caudle’s team convinced 15 World of Warcraft players in their twenties – 14 men and 1 woman – who play the game an average of 23 hours a week, to drag themselves away from their computers and spend some time having their brains scanned using functional MRI.

While in the scanner, Caudle asked them to rate how well various adjectives such as innocent, competent, jealous and intelligent described themselves, their avatars, their best friend in the real world and their World of Warcraft guild leader.

For the early results, read the article, but essentially things aren’t black and white about how we perceive ourselves versus our avatars. No big surprise there. One particularly interesting signpost for future research is the idea that those who perceive themselves and their avatars in a similar way may be the individuals at higher risk for addictive behaviours in regards to their use of virtual environments.

Health Games Research

Health Games Research is a website well worth perusing. It’s a US-based organisation devoted to “research to advance the innovation and effectiveness of digital games and game technologies intended to improve health”. There are yearly grants for research into games and health, with the 2009 funding round announced last week.

The Virtual World’s Story Project (TVWSP) is a partnership between Jena Ball (SL: Jenaia Morane) and Marty Keltz (SL: Marty Snowpaw). We’ve previously covered one of their other story quests and they’ve certainly been prolific in the health and education field.

Their latest project is focused on HIV/AIDS and is titled The Life and Times of Uncle D, which you can get a taste of in this four-minute summation:

This week sees the in-world launch of The Life and Times of Uncle D. It’s occurring on the 1st October at Noon SL time, which is 5am on Friday the 2nd October AEST – you can find out more info here on the TVSWP site.

It’s another example of the power of machinima, and the virtual environments they’re created in, to assist in providing meaning to real world issues.

(For those interested in the use of virtual worlds in sexual health education or in health more broadly, don’t forget to keep an eye on sister-site Metaverse Health.)

For the past couple of years I’ve been aware of the work going on in New Zealand with midwifery training and Second Life, mostly thanks to the updates over at SLENZ.

Machinima maker Pooky Amsterdam dropped me a line about a film she’s helped produce that explains the role of Te Wāhi Whānau – The Birth Place in Second Life. The lead educator on the project is Sarah Stewart (SL: Petal Stransky), with SLENZ Project co-leader, Terry Neal (SL: Tere Tinkel) and Scotland based Russell (Rosco) Boyd also heavily involved.

Take some time to watch the 6-minute machinima:

After walking through the actual build and after watching the machinima, the main impression I’m left with is how midwife-driven this project is. What I mean by that, is the birthing unit is so much better than most in existence in the real world. As a Registered Nurse (but not a midwife), I’ve witnessed half a dozen births and even from that limited perspective I can totally appreciate how much better a birthing environment Te Wāhi Whānau is compared to even the better hospital-based birthing units. As a clinical simulation for midwives, I can see its power as a key adjunct to lab-based learning and practicums. The gamut from initial assessment of labour to initiating breastfeeding and perineal care is covered in a comprehensive way.

The SLENZ team deserve major kudos for their work over the past couple of years – they’re some of the true pioneers in virtual worlds and health.

Over the past few days a product announcement and some interesting research have come together for me in illustrating some of the downsides of heavy regular use of virtual environments. I’m talking specifically about the physical impacts here: we’ve covered the psychological positives and negatives repeatedly (e.g. here and here). In regard to the psychological side, I’ve always believed the benefits and opportunities well outweigh the downsides, which is being recognised by professionals working in the area.

The research that caught my eye comes from the American Journal of Preventative Medicine, as reported by MSNBC. The researchers tested the hypothesis that gamers tended to be more overweight and had poorer mental health than non-players. The results, after surveying 552 people in the Seattle area of the US, showed that the hypothesis was essentially correct. Looking at the overweight issue, most people may say “well gee there’s no surprise there”. The gamer stereotype is certainly one of the overweight male staying up at all hours whilst eating endless bags of potato chips. Like any stereotype there can be distorted echoes of reality and this research is doing just that. I doubt there’s anyone claiming that heavy gaming or virtual environment use is good for one’s physical health in respect to exercise and nutrition. Sure, consoles like the Wii are increasing the level of physical activity but the jury is well and truly out on whether it equates to other forms of desirable physical activity. This research was conducted in 2006 but only published now, with an admission it’s just a taste for further research needing to be done – its findings however do point to the challenges for gaming, and by association, virtual environments.

The product announcement that I saw not long after the research above was for an MMO-gaming mouse produced by Razer, called the Naga. Here’s Razer’s PR pitch for it:

It’s not unique in that there’s no shortage of multi-button gaming mouses. What struck me though was the twelve buttons on the left-hand side that are designed purely for thumb use. Knowing the pace of MMO gaming at times, it seems astounding to me that you’d put one thumb through the trauma of operating twelve buttons continuously. In the five minutes-plus of sales pitch above, you’ll hear the word ‘comfort’ a few times, but that’s it. You’ll also hear a couple of mentions of statements like “playing all day” as qualifications for the level of effort that went into producing the design.

Am I alone in thinking that no matter how good the device’s ergonomics are, relying on one digit to control twelve buttons is a recipe for disaster? Sure, the heavy use of a keyboard for the same activity isn’t ideal either, but usually the repetition is spread around a few more digits if keyboard shortcuts are being used. Of course, gaming is different to broader virtual world use, but in proportion the same issues remain.

My point overall? Virtual environments are really no different to the real world in respects of the need to engage in physical activity. The ever improving development of new interface options may assist, but the reality in the short to medium term is that plenty of real world concentration on nutrition and exercise is needed. The three people I know best who are involved in virtual environments 8-16 hours a day all own pets and tend to have an exercise schedule. Do you?

For the regular virtual worlds follower, there’s nothing too surprising in the findings, but they’re noteworthy all the same:

– Second Life support groups revolved predominantly around disabilities and mental health issues in regards to numbers of members.

– IMVU groups also featured mental health issues heavily,mainly due to a very popular ‘Suicide, Depression, and Relationships’ group.

– There.com skewed toward general health topics with a significant cohort of interest in the disabilities area.

– Kaneva had a slightly different focus on Gay, Lesbian and Transgender issues, as well as autism.

There is a caveat openly referred to by John Norris in his work: the numbers of participants in these groups are relatively small, particularly when compared to the burgeoning 2D health support space with its myriad discussion forums and other community mechanisms. That said, he makes some good assertions:

1. That the advent of virtual worlds provides another means for people to seek highly customised healthcare support, meaning the potential for finding the exact niche being sought is higher as adoption grows.

2. That, like any emerging area of healthcare, there needs to be more research done on the efficacy of the approach.

3. That the lack of access to good quantitative and qualitative data poses a challenge for those who see the need for more research.

Suicide remains one of the issues that pretty much everyone feels queasy discussing. For the survivors of suicide, there’s not choice to discuss it and it’s one of two reasons a presence in Second Life has been created.

Located in Haetae, the purpose is is expression and support. There are two floors, Life and Death. Death is an art exhibition depicting the feelings of those considering suicide. The Life section contains some notecards on related area to assist people considering suicide and those that love them.

It’s a confronting exhibit, which is as it should be. It’s not an easy issue in any sense, which makes it all the more important to discuss and raise awareness around. It’d be easy to say there’s nothing in this exhibit that can’t be found in a much more comprehensive form. That would miss the point: every channel of communication that can make a difference is worthwhile, and I’d have some faith that the efforts here will certainly do that.

If you need more information on the project contact Krissy Sinclair in-world.

DeeAnna Nagel and Kate Anthony are psychotherapists and founders of the Online Therapy Institute. The pair have only recently expanded their work to Second Life, but they have extensive experience in working with people therapeutically online. The pair now have a presence on Jokaydia in Second Life. I caught up with them to talk online counselling / therapy.

Lowell: Can you give a brief outline of your professional experience /qualifications pre-Second Life / online therapy?

DeeAnna: I have a Master of Education in Rehabilitation Counseling and a Bachelor of Science in Mental Health and Human Services. I have worked in the mental health field for nearly 20 years. About 10 years ago I discovered the power of the Internet and began providing online chat and email through a couple of e-clinics. Over the years I have always maintained a part-time practice online and have integrated technology in work settings working with interns, employees and clinical supervisees. I have been training therapists since 2001 about the ethical issues pertaining to technology and mental health. Now 100% of my work life is devoted to either providing online therapy or teaching others about online therapy.

Kate Anthony: I have a Master of Science in Therapeutic Counselling and a Bachelor of Science in Psychology, and am halfway through a PhD on the topic of Technology and Mental Health. At around the same time as I discovered how powerful relationships over the Internet can be and based my MSc thesis on that. From that, I co-authored the British Association for Counselling and Psychotherapy (BACP) Guidelines for Online work (including Supervision) through its 3 editions. I have trained mental health professionals to work online since 2002, have published widely including textbooks, and was recently made a Fellow of BACP for my work and DA and I are both past-Presidents of the International Society for Mental Health Online (ISMHO).

Lowell Cremorne: What was the event that led to you realising the potential of virtual worlds for counselling interventions

DeeAnna Nagel: There was no single event for me; just a realisation that virtual world settings offer another level of sensory experience that could enhance the therapeutic process.

Kate Anthony: I realised this in 2001 after speaking at a conference about Telephone Helplines. The Keynote speaker was head of BTExact Technologies, and he referred to the future of virtual worlds, and avatars specifically, being part of the future of health care. Most of the audience was laughing at the concept -– I wasn’t. I went on to work with him and his team to explore the concept and write a white paper on the topic (Anthony, K. and Lawson, M (2002). The Use of Innovative Avatar and Virtual Environment Technology for Counselling and Psychotherapy. Available online at www.kateanthony.co.uk/research).

DeeAnna Nagel: The potential for therapeutic intervention in virtual world settings is already available – but not necessarily cost-effective for the private practitioner. Second Life is not encrypted and while we could offer therapy using secure methods such as a Sky Box, we have chosen not to. Proprietary software is being developed by companies and institutions for use in SL and other virtual worlds, and at some point private practitioners will be able to provide secure and encrypted services. Until that happens, we can, as you say, utilise our SL office as a way to meet people who want to provide an avatar representation and for other educational and consultancy opportunities.

Lowell Cremorne: What do you think needs to occur for people to be able to trust in-world therapy?

DeeAnna Nagel: Security including encryption is paramount. In addition, virtual world platforms need to be less cumbersome and be able to run on different platforms without the constant risk of technological breakdowns.

Lowell Cremorne: A common component of media coverage of virtual worlds is addiction – for the small percentage of people who may have a definable addiction, can the cause also play a role in the treatment? What I’m getting at here is whether in-world therapy for those addicted to virtual world interaction is a sensible treatment option or a damaging option.

DeeAnna Nagel: This should be taken on a case-by-case basis- I do offer online text-based therapy via chat and email to people who identify with Internet addiction. I think working with addicts inworld allows the client to experience a healthy relationship online and offers a way to model use of technology in appropriate ways. Technology is such a part of our social and vocational fabric now that people need to be able to integrate back to using technology but in healthy ways with appropriate boundaries. The work becomes about establishing and maintaining healthy relationships just as we have done with face-to-face clients for years.

Lowell Cremorne: Rapport-building is key for successful therapy – how best is that done online?

DeeAnna Nagel: Consideration should be given to the disinhibition effect. Online, people are less inhibited and likely to disclose information due to the person’s sense of anonymity. When working therapeutically, on the surface, this can be a plus in establishing rather quick rapport, but therapists also have a responsibility to prepare clients about disclosing personal information too quickly and then helping the client modulate the emotional intensity throughout the process.

Kate Anthony: The concept of “presence” is also important here – where is the client and where are you during the process? Most of my trainees agree post-training that the therapeutic work takes place somewhere between the two pieces of hardware (including mobile hardware) in Cyberspace. The mutual journey – and the rapport that goes with it – seems to take place in a nebulous arena, but actually the understanding by both client and counsellor as to how it exists for them facilitates the rapport.

Lowell Cremorne: How much real-world identification do you believe needs to occur prior to therapy commencing?

Kate Anthony: I think it essential for the client to be able to verify identity of the therapist, but this could be done via a third party – such as a professional organisation. Opinion varies widely from a client-identification point of view. Purists prefer to work with whatever the client is offering, subject to some legal identity checks in some places such as the client possibly being under age. The argument there is that the psyche that the client presents, via avatar or text, is a valid psyche to work with. Other practitioners prefer to make several checks as to how the client exists offline (we feel the phrase “real-world” is outdated, incidentally, so prefer to refer to online and offline). Personally, I feel that with a robust intake form and assessment procedure, further identification may simply get in the way of the therapeutic work which often depends on uniquely online societal norms (such as disinhibition and the perceived anonymity).

Kate Anthony (L) and DeeAnna Nagel (R)

Lowell Cremorne: Is confirming real world gender / age / cultural identity important for good therapeutic outcomes online?

DeeAnna Nagel: Yes- as with face-to-face, the person’s identification is important to determine if the work between therapist and client is a good fit. Cultural differences should be taken on a case-by-case basis.

Kate Anthony: Yes, particularly with regard to age and informed consent.

Lowell Cremorne: What issues / mental health states would you feel uncomfortable dealing with online?

DeeAnna Nagel: For the most part, I am comfortable working with people online that have issues I am comfortable working with face-to-face. As long as I feel competent about the clinical issues and have the proper training, most mental health interventions can occur online. For me, it is difficult to work with someone who is obviously intoxicated or obviously decompensating and showing signs of delusional and irrational behavior- but this is whether the client is face-to-face or online. Certainly, when working via distance, the client’s geographical resources should be determined should crisis intervention become necessary.

Kate Anthony: And that exact point is how I train upcoming online mental health professionals– that with the Internet it is simple to explore a clients alternative crisis interventions based on their geographical location. Other concerns are working with people who are in a relationship that involves domestic violence. Safety issues for the victim come into play if he or she is using a computer that the perpetrator has access to and may be monitoring with a keystroke program.

Lowell Cremorne: Whether it be in a virtual world or via more traditional online methods, do you find you’re less likely to run into personal boundary issues, or is it just as much a challenge?

DeeAnna Nagel: For me, the boundaries are not blurred. I have always maintained boundaries in person and online but with the advent of social networking, I am consulting with more and more professionals who are struggling with this issue. What to do if a client friends their therapist on Facebook for instance and many times the dilemmas are ethical in nature- with regard to either confidentiality or dual relationships.

Lowell Cremorne: Are you aware of any formalised professional associations for online therapists to communicate and if not, how do you see the momentum developing so that this occurs?

Kate Anthony: There is the International Society for Mental Health Online (ISMHO) as mentioned, and more recently ACTO-UK (Association for Counsellors and Therapists Online – UK) – an organisation for UK based online therapists. The latter is holding it’s first conference (online and offline simultaneously) in April. Our fear is that many small organisations will crop up here and there with narrow ideas – what the Online Therapy Institute strives for is a global agreement as to how each of these associations can work together to disseminate knowledge and stimulate growth of the field to the greater good of online work, whether in virtual worlds or via other modalities.

Lowell Cremorne: What are your plans over the coming year for your Second Life work? Have you considered other worlds?

DeeAnna Nagel: We explore other worlds as they appear, and not always necessarily in an obvious way. For example, the Online Therapy Institute has a strong interest in the prevention and treatment of Cyberbullying, and a virtual world such as Club Penguin, for example, could be instrumental in that aim. Plans for the coming year is to explore those platforms that meet the Institute’s requirements for safe and secure client-therapist interaction, and continue to develop training for conducting therapy in virtual worlds.

You may have heard of TED talks: some of the world’s best thinkers (and doers) speak on some consciousness expanding topics. At the 2009 TED Conference, Juan Enriquez made a fascinating presentation on how the convergence of cell engineering, tissue engineering and robots would lead to the next iteration of the human species. If you have a spare 18 minutes, do watch the following and read on afterwards:

The information provided by Enriquez is likely to have caused a mixture of emotions, including fear, amusement and excitement. The same emotions apply to the current economic situation and also to virtual worlds. To draw a longer bow, Enriquez’s vision is hard to imagine without virtual worlds playing an intrinsic role. They are already perceived as a key collaboration tool, and the same technological evolution Enriquez speaks of will ensure that collaboration becomes more productive. Full walk-throughs of organs are available now in Second Life – it’s reasonable to assume that the much more advanced modelling solutions employed by researchers will find their way online in coming years.

In 2009, the virtual worlds industry is talking about the momentum in virtual meeting spaces and the growing work on interoperability. The innovators Enriquez cites are are creating stem cells from skin or robots that can already pass the physical equivalent of a Turing Test. The latter are well and truly the most groundbreaking but the former will continue to play a pivotal supporting role.

Enriquez paints a bleak picture in his presentation of the economic wave that is currently causing so much distress worldwide. He rightly shows a much bigger second wave of technological change occurring. Innovation is undoubtedly key to surviving the first economic wave. The second wave contains a lot of promise but it may also drown a lot of people. Those that it doesn’t overpower may literally be another human sub-type. It throws a whole new light on the term ‘geek’. They may rule the earth after all.